I'm a Visiting Professor at Cardozo Law School where my research focuses on media law with a particular focus on law and social media. Previously, I was the Editorial Counsel for Forbes magazine and Forbes.com. E-mail me at kai.falkenberg@yu.edu.

Why Rating Your Doctor Is Bad For Your Health

SUFFERING FROM A TOOTHACHE, a South Carolina woman headed to her local emergency room a few months ago. The doctor there responded by administering Dilaudid, a powerful intramuscular narcotic typically reserved for cancer-related pain. Why, his nurse queried, was he killing a flea with a sledgehammer? Afraid of malpractice? No, the doc replied, Press Ganey. “My scores last month were low.”

Press who? The little-known company has become a hated target of hospital physicians, outstripping even trial lawyers. Utter its name in an emergency room and you’ll likely unleash a cloud of four-letter words. Based in South Bend, Ind., Press Ganey is the nation’s leading provider of patient satisfaction surveys, the Yelp equivalent for hospitals and doctors, and a central component of health care reform. Over the past decade the government has fully embraced the “patient is always right” model–these surveys focus on areas like waiting times, pain management and communication skills–betting that increased customer satisfaction will improve the quality of care and reduce costs. There’s some evidence they have. An ObamaCare initiative adds extra teeth, to the tune of $850 million, reducing Medicare reimbursement fees for hospitals with less-than-stellar scores.

Catering to Patients Can Be Harmful to Their Health

Accordingly, hospitals kowtow to Press Ganey. In November nearly 2,000 administrators spent $1,100 or more each to attend Press Ganey’s glittery client conference–a closed-to-the-public affair in Washington, D.C., with keynotes by Jeb Bush and astronaut Mark Kelly and his wife, former congresswoman Gabby Giffords. Press Ganey is helping hospitals fulfill their mandated obligation. Some have taken an extra step, tying physicians’ compensation to their ratings.

That may sound like a good thing. Why shouldn’t you grade the quality of your medical care, the way that you pass judgments on other services, whether hotel stays via TripAdvisor or contractors via Angie’s List?

The short reason: The current system might just kill you. Many doctors, in order to get high ratings (and a higher salary), overprescribe and overtest, just to “satisfy” patients, who probably aren’t qualified to judge their care. And there’s a financial cost, as flawed survey methods and the decisions they induce, produce billions more in waste. It’s a case of good intentions gone badly awry–and it’s only getting worse.

FOR ALL THE DOCTORS OUT THERE CARPING about these surveys, a message from Press Ganey CEO Patrick Ryan, a veteran health care executive: Suck it up. “Nobody wants to be evaluated; it’s a tough thing to see a bad score,” he says. “But when I meet with physician groups I tell them the train has left the station. Measurement is going to occur.”

But what exactly are Press Ganey and its two main rivals, the Gallup polling company and the publicly traded National Research Corp., measuring? Customers know what they want when they review spaghetti carbonara for Zagat. But giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine. Last February researchers at UC Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on health care and prescription drugs. They were 12% more likely to be admitted to the hospital and accounted for 9% more in total health care costs. Strikingly, they were also the ones more likely to die.

Why? The UC Davis authors posit that the most satisfied patients have a higher mortality rate because they receive more discretionary services–interventions that carry a risk of adverse effects. Even routine screenings for diseases like prostate cancer can lead to unnecessary drugs and operations with allergic reactions and surgical complications that leave patients worse off. (While the report controlled for age and health status, critics have challenged its methodology and claimed its findings are overstated. But other studies also confirm that patient satisfaction is not always a reliable index of good care.)

“Numerous studies have found that patients are consistently highly satisfied with one of the most common downsides of medical care–false-positive test results and the downstream events that follow,” wrote Dr. Brenda Sirovich of the VA Outcomes Group in White River Junction, Vt., commenting on the UC Davis study. “Almost any unnecessary or discretionary test has a good chance of detecting an abnormality.” Such testing “is a double-edged sword,” explains Dr. H. Gilbert Welch in his 2011 book, Overdiagnosed, often leading to “the detection of abnormalities that are not destined to ever bother us.”

Our health care system already suffers from a “more is always better” fallacy. “Practicing physicians have learned–from reimbursement systems, the medical liability environment and clinical performance scorekeepers–that they will be rewarded for excess and penalized if they risk not doing enough,” says Sirovich. An overreliance on patient surveys, she says, only inflames the problem of overtreatment.

Press Ganey’s Ryan points the finger elsewhere: “If there’s anything going on that’s driving somebody to test more, it’s the fear of malpractice.” For the past few decades that’s certainly been true. Money drives professional behavior for doctors, as it does for virtually everyone else, and the soaring insurance premiums that come with a malpractice suit have surely affected decision making.

But as hospitals and other employers increasingly tie physicians’ compensation to patient wishes, doctors are pushed even further down the dangerous path of overtreatment. Nearly two-thirds of all physicians now have annual incentive plans, according to the Hay Group, a Philadelphia-based management consultancy that surveyed 182 health care groups. Of those, 66% rely on patient satisfaction to measure physician performance; that number has increased 23% over the past two years.

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Patient satisfaction is an important outcome. Patients deserve to have a voice. Appropriate scientific methods and reliable data are incredibly important. As your report observes, a handful of surveys is not an adequate sample size for benchmarking and incentivizing performance.

Yes, indeed. My story is encapsulated in the graphic that shows the report posted in a physicians lounge. The important thing is to measure patient satisfaction in an evidence-based way — encouranging physicians to similarly practice evidenced-based medicine.

I am one of those healthcare providers who have been asked to resign, not fired, a number of times because of patient complaints. Because of that I wrote and published a book titled The Customer is NEVER Right: A Nurse Practitioner’s Perspective in 2012, to tell my story knowing it is the story of many healthcare workers. Recently, I asked a colleague to look at my blog (www.thecustomerisneverright.com) and he replied, “A not so recent article that [found] patients with [customer satisfaction] scores of 5 have the highest mortality.” Baffled by his claim, I set out to find the article he mentioned to include in my blog and serendipitously found the article you published.

This is the book’s synopsis: An earnest yet unsettling account of frontline emergency healthcare in the USA today from the point of view of one man, a nurse practitioner, who struggles to maintain his integrity and his job, and, ultimately, failing, at least in terms of the job. Honesty and agony jump off the page as the author points out the serious problems between healthcare administrations and the transformation of healthcare from a helping profession to just one more profit-driven business.

Healthcare is a time honored profession and the practice of medicine must remain evidence based and not about catering to arbitrary satisfaction scores. Medicine is not Facebook and we should not be concerned by being “liked” or “friended”.

Ms. Falkenberg, you have written a superb article that draws attention to a number of pressing healthcare issues, as does my book, however, we both seem to be preaching to the choir. These issues have been mentioned a number of times before, by a number of authors, in a number of mediums, and continue to fail in grabbing the attention of administrators and policy makers as if they are not paying attention or are not remotely interested, a poignant point I outline in my book.

The purpose of me joining this discussion is to highlight the fact that, even though you are not affiliated with healthcare as your primary profession, you came up with the same objective findings that I, and the many that have replied to your article, have come up with. As noted by your followers’ replies, healthcare workers likely have ten stories for every story you and I could share. Having said that, health care workers are not sniveling as the PG CEO suggested when he exclaimed, “Suck it up.”

Now, we in healthcare can only hope administrators and policy makers will consider your story as neutral, as you do not have a reason to grumble, because our attempts to bring the same pivotal findings to anyone’s attention have fallen on deaf ears.

The train may have left the station, as the PG CEO tells physician groups, but it has gone down the wrong track. Medical care should never come second to customer satisfaction. Not to mention the trail of collateral damage left behind from catering to patients with exaggerated unrealistic emotional expectations. With that said, history bears witness that bad ideas are successful when do-gooders stand by and let the train run down the wrong tracks.

Thank you for writing such a timely, critical, and informative article and hopefully with your investigative journalism and our desire to keep healthcare an honorable profession, we can expose the insidious practice that customer satisfaction rating is in healthcare.

I am one of those healthcare providers who have been asked to resign, not fired, a number of times because of patient complaints. Because of that I wrote and published a book titled The Customer is NEVER Right: A Nurse Practitioner’s Perspective in 2012, to tell my story knowing it is the story of many healthcare workers. Recently, I asked a colleague to look at my blog (www.thecustomerisneverright.com) and he replied, “A not so recent article [found] patients with [customer satisfaction] scores of 5 have the highest mortality.” Baffled by his claim, I set out to find the article he mentioned to include in my blog and serendipitously found the article you published.

This is the book’s synopsis: An earnest yet unsettling account of frontline emergency healthcare in the USA today from the point of view of one man, a nurse practitioner, who struggles to maintain his integrity and his job, and, ultimately, failing, at least in terms of the job. Honesty and agony jump off the page as the author points out the serious problems between healthcare administrations and the transformation of healthcare from a helping profession to just one more profit-driven business.

Healthcare is a time honored profession and the practice of medicine must remain evidence based and not about catering to arbitrary satisfaction scores. Medicine is not Facebook and we should not be concerned by being “liked” or “friended”.

Ms. Falkenberg, you have written a superb article that draws attention to a number of pressing healthcare issues, as does my book, however, we both seem to be preaching to the choir. These issues have been mentioned a number of times before, by a number of authors, in a number of mediums, and continue to fail in grabbing the attention of administrators and policy makers as if they are not paying attention or are not remotely interested, a poignant point I outline in my book.

The purpose of me joining this discussion is to highlight the fact that, even though you are not affiliated with healthcare as your primary profession, you came up with the same objective findings that I, and the many that have replied to your article, have come up with. As noted by your followers’ replies, healthcare workers likely have ten stories for every story you and I could share. Having said that, health care workers are not sniveling as the PG CEO suggested when he exclaimed, “Suck it up.”

Now, we in healthcare can only hope administrators and policy makers will consider your story as neutral, as you do not have a reason to grumble, because our attempts to bring the same pivotal findings to anyone’s attention have fallen on deaf ears.

The train may have left the station, as the PG CEO tells physician groups, but it has gone down the wrong track. Medical care should never come second to customer satisfaction. Not to mention the trail of collateral damage left behind from catering to patients with exaggerated unrealistic emotional expectations. With that said, history bears witness that bad ideas are successful when do-gooders stand by and let the train run down the wrong tracks.

Thank you for writing such a timely, critical, and informative article and hopefully with your investigative journalism and our desire to keep healthcare an honorable profession, we can expose the insidious practice that customer satisfaction rating is in healthcare.

I am one of those healthcare providers who have been asked to resign, not fired, a number of times because of patient complaints. Because of that I wrote and published a book titled The Customer is NEVER Right: A Nurse Practitioner’s Perspective in 2012, to tell my story knowing it is the story of many healthcare workers. Recently, I asked a colleague to look at my blog (www.thecustomerisneverright.com) and he replied, “A not so recent article [found] patients with [customer satisfaction] scores of 5 have the highest mortality.” Baffled by his claim, I set out to find the article he mentioned to include in my blog and serendipitously found the article you published.

This is the book’s synopsis: An earnest yet unsettling account of frontline emergency healthcare in the USA today from the point of view of one man, a nurse practitioner, who struggles to maintain his integrity and his job, and, ultimately, failing, at least in terms of the job. Honesty and agony jump off the page as the author points out the serious problems between healthcare administrations and the transformation of healthcare from a helping profession to just one more profit-driven business.

Healthcare is a time honored profession and the practice of medicine must remain evidence based and not about catering to arbitrary satisfaction scores. Medicine is not Facebook and we should not be concerned by being “liked” or “friended”.

Ms. Falkenberg, you have written a superb article that draws attention to a number of pressing healthcare issues, as does my book, however, we both seem to be preaching to the choir. These issues have been mentioned a number of times before, by a number of authors, in a number of mediums, and continue to fail in grabbing the attention of administrators and policy makers as if they are not paying attention or are not remotely interested, a poignant point I outline in my book.

The purpose of me joining this discussion is to highlight the fact that, even though you are not affiliated with healthcare as your primary profession, you came up with the same objective findings that I, and the many that have replied to your article, have come up with. As noted by your followers’ replies, healthcare workers likely have ten stories for every story you and I could share. Having said that, health care workers are not sniveling as the PG CEO suggested when he exclaimed, “Suck it up.”

Now, we in healthcare can only hope administrators and policy makers will consider your story as neutral, as you do not have a reason to grumble, because our attempts to bring the same pivotal findings to anyone’s attention have fallen on deaf ears.

The train may have left the station, as the PG CEO tells physician groups, but it has gone down the wrong track. Medical care should never come second to customer satisfaction. Not to mention the trail of collateral damage left behind from catering to patients with exaggerated unrealistic emotional expectations. With that said, history bears witness that bad ideas are successful when do-gooders stand by and let the train run down the wrong tracks.

Thank you for writing such a timely, critical, and informative article and hopefully with your investigative journalism and our desire to keep healthcare an honorable profession, we can expose the insidious practice that customer satisfaction rating is in healthcare.

Kai, contact me. This article touches base on many of the reasons I left my position of 12 years to develop the cloud app that addresses these and many other concerns. In this early day of mHealth it is time to lead.

The problem with this type of data collection and reporting has always been reliable data.

I would love to offer several of the Drs frustrated with current industry standard(within this post) the opportunity to help lead and develop this methodology by piloting this app in their practice for a year.

Everyone has been talking about this nonsense for years. My team and I are ready to offer the solution.

Patients do have a voice. They can vote with their feet. At our facilty we have had vastly different ratings on the same question, THE COMFORT OF THE WAITING ROOM, by different doctors whose patients all use the same waiting room. We have had ‘ratings’ when only 3 surveys were returned, that can’t be valid data.

This article raises legitimate concerns. I am an RN at on psychiatric unit in a hospital. Same thing is being incorporated into our system. Whether it works in a medical unit, I won’t speak to that, but psychiatric? no way! Doctors end up prescribing narcotics to already addicted psychiatric patients who are coming into the hospital claiming to be suicidal only to be prescribed the pain pills they can’t afford off the street and can’t get a doctor to prescribe for them on the outside. These are patients who are clearly not in pain as they flint around the unit socializing with others like they are on a cruise ship. Many psychiatric patients are unhappy and they are not in a frame of mind to do anything but complain. My specific area gets a lot of personality disorders who thrive on chaos, try to create chaos, split staff, push limits, disobey rules. When they don’t get away with their childish antics, when they are confronted on their behavior and how it is impeding their ability to get along in the “world” they can become angry and punitive. Punitive especially when asked about patient satisfaction. It’s their chance to seek revenge because they don’t want to change their misguided and maladjusted ways of coping with the world’s stresses. We end up allowing them to get away with anything and the unit begins to resemble a playroom where wild and misbehaved 2 year olds have taken control of their caregivers. Sounds good in theory, does not work in real life. In fact, like the article says, it ends up impeding getting the care the patient actually needs.

Thanks for sharing your experience. Given the epidemic of prescription narcotic abuse, its disconcerting that we are incentivizing docs to prescribe even more drugs. I appreciate you adding your first hand perspective to this conversation.